The disappearing workforce? Why countries in Southeast Asia need to think about fertility rates before it's too late - A report by The Economist ...
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The disappearing workforce?
Why countries in Southeast Asia need to
think about fertility rates before it’s too late
A report by The Economist Intelligence Unit
Sponsored byTHE DISAPPEARING WORKFORCE?
WHY COUNTRIES IN SOUTHEAST ASIA NEED TO THINK ABOUT FERTILITY RATES BEFORE IT’S
TOO LATE
Contents
About this report 2
Executive summary 4
Introduction6
A history of the fall: declining fertility in Southeast Asia 7
Cultural and economic diversity across the region 12
The policy response 14
Opportunities for improvement: what does the evidence say? 17
Discussion and recommendations 21
References23
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About this report
T his report aims to understand the factors behind declining birth rates in Southeast Asia and
examine what policymakers can do to address the issue. We focus mainly on three Southeast
Asian countries: Thailand, Vietnam and Malaysia. For each country we investigate how they are
managing their falling fertility levels and provide recommendations for how governments in the region
might improve relevant policies: what can policymakers do to stop or maybe even reverse the current
trend? We also review the global evidence-base on the effectiveness of family friendly policies and ART
(assisted reproductive technologies), with a focus on evidence relevant to the region.
The Economist Intelligence Unit carried out a literature review on fertility rate interventions in
Thailand, Vietnam and Malaysia and conducted interviews with local experts. We would like to thank
the following individuals for sharing their insights and experience.
Thailand:
l Chanwit Wasanthanarat, Director, Thai Health Promotion Foundation
l Kamthorn Pruksananonda, Associate Professor, Director of Chula IVF, Department of OB/GYN,
Chulalongkorn Hospital
l Rossarin Gray, Associate Professor, Director of Institute for Population and Social Research, Mahidol
University
l Sorapop Kiatpongsan, Assistant to the President for Research and Innovation, Faculty of Medicine
and Sasin School of Management, Chulalongkorn University
l Vipan Prachuabmoh, Associate Professor, Dean of College of Population Studies, Chulalongkorn
University
Malaysia:
l Eeson Sinthamoney, President of Obstetrical and Gynaecological Society of Malaysia, Medical
Director and Fertility specialist, Sunfert International Fertility Centre
l Tey Nai Peng, Dr., Faculty of Economics and Administration, University of Malaya
l Wong Pak Seng, Managing Director and Fertility specialist, Sunfert International Fertility Centre
l Zainul Rashid Mohd. Razi, Professor. Dato’ Dr., Universiti Kebangsaan Malaysia Specialist Centre
Vietnam:
l Nguyen Viet Tien, Professor, Deputy Ministry of Health, President of Vietnam Gynaecology and
Obstetrics Association. Director of National ART
l Nguyen Thi Ngoc Phuong, Professor, President of HOSREM
l Le Quang Thanh, Director of Tu Du Hospital
l Ho Manh Tuong, General Secretary of HOSREM, Head of My Duc IVF chain
l Le Hoang, Associate Professor, Head of Tam Anh IVF center
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Old-age support ratio is the ratio of the number
Some key definitions:
of persons aged 15 to 64 years potentially
Total fertility rate (TFR) represents the number economically supporting each person aged 65
of children that would be born to a woman if she years or over.
were to live to the end of her childbearing years
and bear children in accordance with age-specific Ageing societies have a proportion of 7-14% older
fertility rates. persons (persons aged 65 or older).
Replacement rate is the TFR at which women Aged societies have a proportion of 14-21% older
give birth to enough babies to sustain the persons.
population levels.
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Executive summary
From 5.5 to 2.4, and still falling
Socioeconomic development is often found to be associated with falling birth rates, and Southeast
Asia is no exception. The region has achieved remarkable economic growth in recent decades, much
of it driven by its flexible and skilled work force. However, the fertility rate of Southeast Asia has drifted
from 5.5 in 1970 down to 2.4 in 2015 and continues to fall. This demographic shift leads to an ageing
population, with greater old-age dependency, and puts at risk the very workforce that has driven the
region’s economic growth. The cost of policy inaction in the field of family planning will be seen in
smaller than hoped GDP figures, and proportionally rising care costs. We ask what has caused these
falls in fertility rates, and what countries can do to try and turn things around.
A brief history lesson shows us that an important factor in the decline of fertility rates in many
Southeast Asia countries was the adoption of family planning programmes to curb the population
explosions of the 1970s. The success of these polices still linger over countries now facing the opposite
demographic problem. Other factors driving the fall in fertility levels include rapid urbanization and
migration from the country to the city: these shifts contribute to the higher costs of raising children
and the lack of affordable housing for family building. As with the rest of Asia, women are increasingly
gaining access to higher education, and consequently are postponing marriage and childbirth to pursue
economic opportunities. We also find that families are shifting their focus from ‘quantity’ to ‘quality’,
where a greater emphasis is placed on raising children with a better quality of life rather than the
number of children. Finally, alongside these social and economic factors, biological infertility persists as
well: most people in the region have a poor understanding of age’s impact on fertility, or of the impact
of factors such as a poor diet or smoking. People tend to underestimate age’s impact on fertility and
overestimate the potential of assisted reproductive technology (ART) as a solution.
The diverse fertility landscape reflects the heterogeneity of the region
The fertility landscape in Southeast Asia is complex: not only is there the high cultural and ethnic
heterogeneity of the region, but also high rates of economic inequality within and between countries.
These differences are reflected in different fertility rates. For instance, ethnic Malay families in Malaysia
are larger as their culture favours larger families and communities, compared to the ethnic Chinese
whose concern is more on family lineage. This unequal development across countries in Southeast Asia
makes the creation of policy challenging, as it needs to address the diversity of peoples and cultures
in the region. As most countries in Southeast Asia are developing nations, funding is also a barrier, and
infertility may not be perceived as a sufficiently urgent problem.
Pro-natalist policies have been sporadically implemented, but more needs to
be done
A number of Southeast Asian countries have implemented some form of pro-natalist policy. These
range from parental leave entitlements to subsides for ART to financial incentives, such as tax and cash
bonuses. However, with increasing urbanisation and female participation in the labour force, more
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efforts could be made to decrease the cost of child rearing without disincentivizing work for women.
Family friendly policies are needed to give greater flexibility for parents to both work and raise a family.
Such policies may include the extension of parental leave to men and the improvement of workplace
regulations to balance work and family duties. The provision of workplace child care would help
working mothers juggle their responsibilities, while breastfeeding rooms and supplies would support
new mothers—particularly in factories, where women often make up most of the workforce.
On the financial side, tax reliefs, cash incentives and child care subsidies are undoubtably welcome
by parents. However, evidence is mixed on whether they help increase fertility rates. Similarly, making
ART affordable by providing subsidies is often found to increase the number of ART births, but
evidence of impact on national fertility rates is lacking. Nevertheless, there is also a moral argument
here: that improving accessibility to ART is the right thing to do as it offers hope for couples who
would otherwise remain childless. And this comes to the heart of the conclusions we put forward: that
governments should not look simply to increase their total fertility rate, but rather prioritise how they
can make the country as family friendly as possible. Parenthood should be supported and celebrated,
and families need to know the government is on their side.
Conclusion and recommendations
We recommend that there are four principles around which governments can build effective policy.
The first is to extend family friendly policies as described above. The second it to invest in raising
population awareness of fertility matters, to ensure that people are knowledgeable about family
planning and fertility preservation. The third is to improve access to infertility treatment, such as ART.
Fourth and finally, is the need to ensure affordable housing, in order to encourage family building.
Governments need to act now.
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Introduction
F ertility rates in Southeast Asia have been falling over the past 50 years. Some countries have seen a
gradual decline, while in others rates have tumbled precipitously. In the 1970s, women in Southeast
Asia were marrying young and bore an average of five children. Today, however, women are marrying
significantly later in life and bear an average of two children.1 While many Southeast Asian countries
see their birth rates fluctuating around the replacement level of 2.1 children, it is expected that in most
cases the birth rate will not remain at that level, but rather continue to decline.
Variations in fertility rate is sometimes simply due to countries being at different stages of socio-
economic development. But there are other drivers. For example, to curb the population explosions
of the seventies, most countries adopted family planning programmes, some more stringent than
others. Alongside these policies, increased female education and labour force participation has often
contributed to a delay in marriage and childbirth, leading to a reduced birth rate.
Southeast Asia has achieved remarkable recent economic growth: it is presently the sixth-largest
economy worldwide, with a GDP of about 3.3% of the global total.2,3 By 2030, ASEAN (The Association
of Southeast Asian Nations, an intergovernmental organization comprising ten countries in Southeast
Asia) aspires to triple their per capita GDP, up from a current figure of $3,000 to more than $9,000.3 This
tigerish economic growth has been driven in large part by the labour force,2 and so the demographic
changes associated with falling fertility levels will put ASEAN’s economic and financial aspirations
at risk.3
By 2050, it is estimated that 21.1% of the population in Southeast Asia will be 60 years or above;
the old age support ratio will be 4.2.4 This means that one older person is supported by just over
four people of working age—a situation that can be challenging in the absence of strong pensions or
social security systems. The transition from an ageing to an aged society (i.e. from a society in which
7-14% of persons are aged 65 or older, to one where 14-21% of persons are) for countries in the region
will be rapid: 22 years in Thailand and 19 years in Vietnam. Thailand will become an aged society in
2024 and Vietnam in 2039. Compare this to Sweden and France, where it took 85 years and 115 years,
respectively.4 With limited time and resource, it will be difficult for Southeast Asian countries to adjust
to the needs of an aged population. A large portion of the country’s expenses will go to healthcare and
infrastructure costs for the elderly, just at the time when the working-age population—needed to drive
economic growth and pay their taxes—is in decline.
When it comes to policy responses to this dawning reality, the countries of Southeast Asia are
starting from very different levels. Some are still officially pursuing population control measures, while
others have instituted pro-natalist policies. Policies extend from basic maternity leave to incentivising
schemes such as tax and cash benefits, or subsidies for child-related costs. An emerging area for
policy intervention is ART (assisted reproductive technologies), which includes technologies such as
hormonal medication, in-vitro fertilization and intrauterine insemination. This report examines the
main drivers for falling birth rates in Southeast Asia and the current policy responses. Through a review
of the evidence and interviews with local experts, we offer some thoughts and recommendations on
how countries in the region may be able to curb falling fertility rates.
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A history of the fall: declining fertility in
Southeast Asia
T he fertility rate of Southeast Asia was 2.4 in 2015, falling from 5.5 in 1970.5 Although the region’s
current fertility rate is slightly above the replacement rate of 2.1, it is projected to fall to the
replacement rate by 2030.5 However, history shows that countries do not settle at 2.1, but rather that
fertility levels continue to decline. Out of the ten ASEAN countries, the fertility rate of six countries has
already fallen to below replacement level. The remaining four—Cambodia, Indonesia, the Philippines
and Laos—remain above 2.1.6 Of our three case study countries, the fertility rates of Malaysia, Vietnam
and Thailand in 2017 were 1.90, 2.04 and 1.58, respectively.7,8,9
Figure 1. Total fertility rate of Southeast Asia countries from 1970 to 2100
(TFR; children per women)
Brunei Cambodia Indonesia Laos Malaysia Myanmar
Philippines Singapore Thailand Timor-Leste Vietnam
8.0 8.0
Historical rates Predicted rates
7.0 7.0
6.0 6.0
5.0 5.0
4.0 4.0
3.0 3.0
2.0 2.0
1.0 1.0
0.0 0.0
1970-1975
1975-1980
1980-1985
1985-1990
1990-1995
1995-2000
2000-2005
2005-2010
2010-2015
2015-2020
2020-2025
2030-2035
2040-2045
2050-2055
2060-2065
2070-2075
2080-2085
2090-2095
Source: United Nations Population Division, 2010.10 2095-2100
The rate of fertility decline is not constant across countries, due to them being at different stages of
demographic transition, although the trend is clear (Figure 1). There are a number of reasons why rates
are falling.
Family planning programmes
National governments have had varying perceptions of fertility issues; these perceptions have
shaped policies (Table 1). For example, in the 1970s and 1980s fertility reduction was an important
aim for Thailand, Vietnam, Indonesia and Singapore: in these countries, family planning programmes
advocated strongly for a small family size.1 Governments in the Philippines saw things differently,
resulting in weak family planning efforts.11,12 Anti-natalist policies were delayed in Cambodia, where the
family planning program was only introduced in 1995 due to many years of unrest during the Khmer
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Rouge period.1,6 In contrast, Malaysia took a pro-natalist stance in 1982 and never had a policy to limit
family size.1
Table 1. Brief history of family planning programmes and policies for selected Southeast
Asian countries
Country Year Family Planning Policy Period of Objectives and action taken
Program started significant policies
Thailand 1970 National Family 1970 – 1996 Population growth rate reduction. Promotion
Planning Program of contraceptives and small family size
1997 – 2011 Maintaining fertility rates at replacement levels
2011 – present Prevent falling fertility rate by introducing pro-
natalist policies
Vietnam 1975 Population Policy 1975 – 1983 Promotion of two-to-three child policy
1993 – 2000 Adoption of National Family Planning Policy
that include one-to-two child policy to reduce
fertility rate to 2.9 by 2000
2001 - present Decreasing fertility to replacement level
Indonesia 1967 Family Planning 1967 – present Establishment of the National Family Planning
Programme Institute to promote fertility welfare
Singapore 1966 Old Population 1972 - 1984 ‘Stop at Two’ policy - Anti-natalist measures
Policy such as incentives for small families and
disincentives for large families
New Population 1987 - 2000 ‘Have three or more if you can afford it’ policy -
Policy Pro-natalist policies to promote more births
New Initiatives 2001 - present Implementation of Marriage and Parenthood
package focusing on promoting work-life
harmony and family-friendly work practices,
with financial incentives such as the Baby
Bonus Scheme and tax rebates
Cambodia 1995 Birth Spacing 1995 – present To reduce undesired pregnancies and maternal
Policy and new-born mortality by promoting
maternal and child health through greater
birth intervals
Rapid urbanization and migration
Southeast Asia has seen rapid urbanisation and development. Migration into cities is often attractive to
people in pursuit of economic opportunities; earning a higher salary and achieving—the theory goes—a
better standard of living. However, city life comes with a high cost of living, and raising a child in the city
is more expensive than in rural areas. Therefore, you need a yet higher salary. This increased outlay has
invariably necessitated a dual-income family unit, in order for its members to maintain an acceptable
standard of living. Because many women find themselves working outside the home to earn a paid
wage, they face conflicting roles between work and family.
Besides within-country migration, there is increasing migration by women from rural areas to
other countries, especially for low skilled jobs such as domestic work.13 These migrants are hired on
a work permit, and are less eligible for social protection coverage and face more vulnerability in their
employment.14 Pregnancy for these migrant female employees would result in job loss and they would
likely be forced to return to their home countries.13
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Urbanisation is also closely intertwined with modernisation. This has brought about the availability
of contraceptives, which has played a big role in declining fertility.6 To curb the earlier population
explosion, family planning programmes in the 1970s encouraged the use of contraceptives.1
Contraception provided a solution for couples to have their desired number of children, giving them
more control of the family size that they wanted.
A lack of affordable housing
Another inevitable consequence of rapid urbanisation is the resulting squeeze on housing stock. In
Thailand for example, rural migrants find their new living places smaller, while their daily cost of living
rises; this combination means that many migrants are unable to bring their children with them to the
city.15 As a consequence of this, the United Nations reports that the number of skipped generation
households—where grandparents find themselves raising grandchildren with little or no input from the
parents—has doubled in the past 25 years, mostly in the rural parts of Thailand.16
In Hong Kong, research has suggested that there is a negative correlation between housing prices
and fertility: this may help to explain the region’s 65% decrease in fertility rates over the past four
decades.17 House prices throughout Southeast Asia continue to rise; indeed, Dr Kiatpongsan from
Thailand highlighted that “the high cost of housing is a financial difficulty for couples trying to manage
their work and build a family. Most couples would want to be financially ready before they think about
having children.” This isn’t only an issue in Southeast Asia. Haghdoost and colleagues found that policy
makers in Iran perceived high housing prices as an obstacle to marriage18, while a global review of high-
income countries found that increasing affordable housing was a way to address declining birth rates.19
Increasing education of women
Improvements in women’s education has increased female participation in the workforce, meaning
that many women postpone marriage and childbirth in order to pursue economic opportunities.
Professor Prachuabmoh observed that “women are delaying marriage and studying longer.” With
more education, more women work, but professional and maternal roles are sometimes proving
incompatible.6 Women engaged in formal, particularly graduate-level professions tend to delay
marriage and childbirth more than women working in the informal sector.20
The impact of women’s education on fertility has been widely studied in Malaysia since 2002. Using
national data from 1980 to 2012, it was calculated that for each 10% increase in female participation in
the workforce, fertility rates decreased by between 3.3 to 7.3%, while for each 10% increase in female
education, fertility rates fell by between 0.4 to 2.1%.21 Educated women also tend to desire a smaller
family size. According to Dr Tey, the degree of education of wives “showed the sharpest differentials in
family size distribution”. A study from 2002 showed that more than 50% of women without schooling
or only primary education have five or more children, while this is the case for just 18.4% of women
with tertiary education.22 While Malaysia’s total fertility rate has declined since then, the proportional
differences between more and less educated women have likely remained similar.
From quantity to quality
A chief reason for the desire for a smaller family size is the shift from ‘quantity’ to ‘quality’. The ‘quality-
quantity trade off’23 describes how some couples are concentrating their finances to ensure their
children want for nothing; placing more importance on producing children with a better quality of
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life rather than the number of children.6 The higher cost of education, and the high opportunity cost
of women’s time due to greater employment opportunities and increased cost of living, means that
more couples are thinking quality over quantity.21 Dr Hoang from Vietnam pointed out that “raising
children with a good quality of life has become a challenge for parents; far from the usual concerns
about providing basic needs and resources for their children.” This observation was also mentioned by
Professor Zainul from Malaysia: “most people emphasize on quality and not quantity to ensure that
their child grows up in a stable environment with good education. To do that, proper contraception
becomes part of their lives. More time can be devoted to the first child before the next one.”
Poor understanding of how fertility declines with age
Awareness of how fertility declines with age is poor in Southeast Asia. Most of our commentators
observed that the majority of the region’s population underestimate age’s impact on fertility and
overestimate ART as a solution for their infertility issues. It was argued that people needed to have
a better understanding of the disadvantages of both ‘too early’ childbearing and ‘too late’ family
building.24 Dr Phuong highlighted that the key to preventing infertility is to educate young couples in
Vietnam about how fertility declines with age, and encourage them to seek professional help after
a year of marriage if they are unsuccessful in getting pregnant. Dr Pruksananoda, from Thailand,
informed us that “working women are delaying marriage and childbirth because they do not recognise
the higher risk of chromosomal abnormalities and the reduced chances of pregnancy as they age”.
Similarly, Dr Thanh, from Vietnam, commented that “people are not very aware about reproductive
issues, infertility and the reasons for infertility. More education is needed on this to help families
improve their family planning.”
Rising infertility
Partly because of this poor awareness, rates of infertility are on the rise for both males and females.
Infertility is partly driven by lifestyle and environmental factors, such as a poor diet and smoking,
but also of course, age.25 For females in particular, an important predictor of subfertility is age when
embarking on a first pregnancy.25 The likelihood of infertility increases gradually with age, but then
starts to significantly rise at around the age of 32 (Figure 2).26 At 37 years of age, the rate of increase
accelerates further, accompanied with poor oocyte quality.26 Dr Sinthamoney from Malaysia remarked
that “infertility rates are on the rise for the simple reason that women are delaying childbirth, especially
in the educated urban population”.
Infertility is an issue for men too. Subfertility due to the number, motility and abnormality of sperm
are being increasingly observed by Professor Zainul in his fertility clinic in Malaysia. He also notes that
“the WHO has decreased the standards of sperm count over the years to accommodate for male
subfertility”.
Infertility is often not recognised as a medical illness and hence tends not to be reimbursed or
covered under health insurance. Payment for infertility treatment is therefore largely out of pocket, and
its high cost can be a barrier to access. Dr Pruksananonda from Thailand notes that patients who seek
treatment for gynaecological diseases do not mention their concerns about infertility to physicians
because “any mention of infertility in their medical history will be used to reject reimbursement by
insurance companies as it is not considered as a disease.”
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Figure 2. Likelihood of infertility increases dramatically with age
(%)
Likelihood of getting pregnant Likelihood of infertility
100 100% 100
90 86% 90
80 78% 80
70 69% 70
63%
60 60
52%
50 50
40 36% 40
30 30
32%
20 20
15%
10 8% 10
3% 5% 5%
0 0% 0
20-24 25-29 30-34 35-39 40-44 45-49 50+
Source: Khatamee & Rosenthal, 2002.
Gynaecological diseases such as polycystic ovary syndrome, endometriosis and presence of fibroids
are commonly found in women with fertility problems; their treatment can increase the chance of
pregnancy.25 However, Dr Pruksananonda pointed out that treatment varies depending on whether
the patient intends to try for a child. “Some physicians would use conventional, conservative methods
for treatment—that do not aid pregnancy—if the woman does not mention her intent of getting
pregnant.” But mentioning an intention to get pregnant may put in jeopardy reimbursement claims. It’s
a vicious cycle.
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Cultural and economic diversity across the
region
P olicies to halt or reverse declining fertility rates will vary different across the region. After all,
Southeast Asia is a complex region and no one approach is likely to fit all countries. While falling
fertility rates can be attributed to factors within countries, there are also regional drivers. We describe
here some key commonalities, and differences, across the region, and how they affect fertility rates.
Cultural differences between countries
Southeast Asia is a region of high cultural and ethnic heterogeneity, where multiple cultural and
religious factors influence family structure and family planning policies. Dr Sinthamoney commented
that “family size has both a cultural and educational component”. For instance family lineage is
important for the ethnic Chinese in Malaysia, and so more families are predominately concerned
about the gender of their children (the United Nations reports that China has the highest sex ratio of
116 boys per 100 girls from 2010 to 2015, well above the average ratio of 104 boys per 100 girls).5 On the
other hand, ethnic Malay families are relatively large because their culture favours larger families and
communities. Cultural factors however are being weakened by educational gains: Dr Sinthamoney
added that “when people become more educated, they realised that it is difficult to manage a large
family and they prefer to control their family size”.
Religious diversity also plays a role. The contraceptive prevalence rate in the Philippines increased
at a much slower pace over the decades, with low family planning efforts due to strong opposition
from the Catholic churches.6 Malaysia on the other hand took a pro-natalist stance, and fertility rates
are highest in states that are governed by Islamic parties with the most pro-natalist teachings22 Indeed,
uptake of contraception has varied among Southeast Asia countries, with some countries achieving
high contraceptive uptake—and therefore lower fertility rates—faster than others.
Southeast Asia is still perceived to be a male dominated society. There remains a lack of male
participation in most households, despite the improved socioeconomic status of females across the
region. Dr Tey highlighted that Malaysia has a “low female participation in the workforce” of 54.8%,28
the lowest in Southeast Asia (Cambodia has the highest, at nearly 80%).29 In addition, Professor
Prachuabmoh from Thailand commented that “women are in the sandwiched generation, who have to
take care of their children and older parents” making it difficult for women to juggle both their jobs and
the domestic chores. Dr Phuong also highlighted that “many women in Vietnam do not expect the men
to share all the domestic chores and are contented if they are willing to help”. Professor Prachuabmoh
is concerned that the unequal division of labour in the household will be a “conflicting issue with the
expectations of women who have a higher education”; she had conducted a study on gender roles in
Thai families and noted that “women expect that the household chores should be shared with their
husbands”. Many commentators agree that the ongoing lack of recognition in Southeast Asia of gender
inequality in the household and workplace would exacerbate fertility decline.
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High inequality within and across countries
Economic inequality is common within and across the countries of Southeast Asia, and often correlates
with rural and urban areas, and sometimes cultural and ethnicity differences. This pattern of highly
unequal development across a country makes it challenging for policy making to address the needs
of the various groups in the population. Professor Tien from Vietnam points out that “population
policies can be difficult to design because if too many resources are diverted to support one group
of people, other parts of the population may feel neglected.” As most Southeast Asia countries are
developing nations, funding is a barrier to implementing multiple policies at the same time. Professor
Prachuabmoh highlights that “the demographic transition of Thailand is like that of developed
countries. Thailand has a low fertility rate and is moving towards an ageing society, but it is still a
developing country.” She further adds that, “unlike other wealthier countries that are able to provide
welfare for their people, resources are limited in Thailand. We do not have sufficient welfare funding to
support everybody on every issue.” Dr Thanh from Vietnam expressed a similar view when explaining
the delay of implementing pro-natalist policies: “infertility is not a critical problem to solve immediately
because most developing countries are busy dealing with urgent healthcare problems such as
infectious diseases or primary healthcare access.”
Unequal development within a country also reveals the limitation of total fertility rate as a national
level measure of fertility. As highlighted by Dr Kiatpongsan from Thailand, “total fertility rate as one
number cannot capture the fertility landscape across the country.” Decisions about family planning
differ between the rural and urban areas, driven by unequal economic and social development. Rural
areas tend to have higher birth rates and fewer infertility issues compared to urban areas.
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The policy response
M any policies have been tried, and sometimes abandoned or even reversed, in countries across
Southeast Asia. We describe an overview of initiatives across the region.
Parental leave
Maternity protection and parental leave entitlements ensure basic rights to maternity leave and access
to medical care, as well as protection against discrimination, dismissals and loss of income during
maternity leave.13 Maternity protection is legislated in the labour and employment acts in all countries,
although the duration of maternity leave varies. The minimum legislated duration of maternity leave
for Malaysia, Thailand and Vietnam is 60 days, 90 days and 6 months, respectively.13 Maternity leave
entitlement also varies with the number of previous births the woman has had: leave is applicable for
up to five births in Malaysia or two births in Thailand; there is no limit in Vietnam.13 However, employers
may choose to grant extra maternity leave if they wish to do so.
The extension of leave to fathers signifies that men should be involved in child rearing.1,30 However,
paternity leave is limited in many countries. And when available, length of leave, and whether it is
paid or unpaid, varies. Myanmar and Singapore offer the longest paid paternity leave of two weeks in
the region,31 while in Cambodia, there are no specific paternity leave entitlements in the labour law.32
Paternity leave in Malaysia and Thailand is only available to civil servants, with 7 days of paid and 15
days of unpaid leave respectively,16, 33 although some private organisations offer paid paternity leaves at
their own discretion. Vietnam has a more generous paid paternity leave: all Vietnamese employees are
entitled to at least 5 days, and up to 14 days of paid paternity leave.35 However, the uptake of parental
leave by men is low, especially when the leave is unpaid.30
Tax incentives
Tax incentives are offered by higher middle-income countries such as Thailand, Malaysia and
Singapore. They are designed to encourage couples to give birth, by financially aiding couples in
supporting their dependent children. Some tax incentives are delivered as part of pro-natalist policies
to encourage couples to have more than one child; for instance, by having higher tax concessions for
subsequent children. Since 2016, a tax relief of RM2,000 per child is given to parents in Malaysia,34 while
parents in Singapore can claim the Parenthood Tax Rebate of S$5,000 for their 1st child, S$10,000 for
their 2nd child, and S$20,000 for each subsequent child.36 This Parenthood Tax Rebate is part of the
Marriage and Parenthood package, consisting of pro-family incentives and benefits, implemented since
2001 to support couples in building families.36 In Thailand, the Ministry of Finance has recently increased
the tax deduction allowance. Previously, a tax deduction allowance of 30,000 baht was granted for up
to three children only. However, to encourage more births, 60,000 baht of tax deduction allowance is
now granted per child.37
Tax benefits can additionally be extended by organisations to create family friendly practices at the
workplace. As part of their Family Friendly Policies, the Ministry of Women, Family and Community
Development in Malaysia offers a 10% tax reduction per annum for up to 10 years to private sector
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employers who set up child care centres at the workplace.33 However, tax incentives have their
limitations: they are not able to incentivise non-tax payers in the informal sector and are more likely to
benefit already relatively prosperous families.38
Cash incentives
Cash incentives are another route for governments to provide financial support for parents—often
delivered as child support grants to lower income families under a social security act. In Thailand,
females insured under the act are given 13,000 baht for each delivery. Also, a monthly cash allowance of
600 baht is given per child until three years of age for families with a monthly household income lower
than 3000 baht per person.16 In Vietnam, mothers receive two thirds of their income before delivery as
part of the maternity benefits that is paid by the social insurance fund.13
Cash incentives may also be given within a pro-natalist agenda to encourage couples to have
children regardless of household income. For instance, the Baby Bonus Scheme in Singapore gives
out cash gifts to new parents. To encourage more births, couples receive a higher cash amount for
the third and subsequent children.39 Over the years, the Scheme has been enhanced with increasingly
higher cash amounts. In Malaysia, cash incentives are also given to couples for babies born in certain
states. Such incentives include Tabung Warisan Anak Selangor in the state of Selangor and the Anak
Emas program in the state of Penang.40, 41 However, cash incentives are not effective for higher income
families: Dr Pruksananonda commented that “providing monetary incentives will not encourage the
desired group of educated working women to give birth”.
Government support for ART
Two of the three countries that are the focus of this report provide government support for ART in
public hospitals: Vietnam and Malaysia. However, funding is allocated to the facilities—not to patients.
This means that while government may support the construction and setting up of new facilities, there
is generally no funding for people wishing to undergo ART procedures, and so patients have to pay out
of pocket. Social health insurance in Vietnam does not cover infertility treatment,42 while in Malaysia
there are just five government-funded fertility centres43 and subsidies are only given for hormonal
injections and drugs to stimulate the production of sperms and eggs. Government provided fertility
treatment in Malaysia, when available, largely depends on availability of funds, and as pointed out by
Dr Wong, “these funds are often insufficient, hence the number of IVF cycles performed in Malaysia is
much less compared to other countries with a similar population size”. In Professor Zainul’s experience,
“payments of ART procedures are fully out of pocket and cannot be claimed from the government”.
One of the reasons why funding for treatment tends not to be widely available in the region is that
infertility is not recognised as a medical condition. Dr Pruksananonda notes that “the number of fertility
clinics in public hospitals is limited due to the lack of budget as infertility is not categorised as a medical
illness.” Without this funding, patients are unable to seek treatment in public hospitals and have to go
to private clinics. These clinics are not only more expensive but may also have long waiting lists.
ART facilities in Thailand and Malaysia are dominated by the private sector, serving a significant
number of international patients; along with Singapore, they are popular medical tourism
destinations.44 In recent years, the Malaysian government has increasingly recognised the potential of
fertility treatment for the development of their medical tourism sector.45 ART procedures in Vietnam
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are mostly limited to the public sector. This is largely due to the restriction of privatization of the
medical services industry.46 Dr Tuong highlighted that “Vietnam has around 30 IVF centres, and the IVF
programmes are centred around providing affordable services for the local population, as most IVF
cycles are performed in public hospitals.” IVF programmes started in 1997 in Vietnam, and “brought
happiness to many struggling couples by enabling them to conceive children” as commented by Dr
Phuong.
Looking ahead, Dr Sinthamoney commented that public funding of infertility treatments would
prompt the opening of more fertility clinics in Malaysia. These in turn would help improve access for
people living in suburban or rural areas: “when it is funded, you will see more equitable provision of
healthcare”. Additionally, Dr Wong is confident that “there will definitely be an increase in fertility
treatment with ART in Malaysia even if the subsidies are not full, and may be only used for a few cycles,
or if patients are allowed to use their provident funds.” At the moment, the Employees Provident Fund
(a compulsory savings plan for private sector workers in Malaysia) cannot be withdrawn to offset the
cost of ART services, with most people currently paying out of pocket for ART. While commentators
agreed that funding is important, it needs to be considered within the wider package of healthcare
services. For example, while Dr Kiatpongsan in Thailand said that “people should be given the right
to build a family, and the government should support those with biological difficulties in getting
pregnant”, he also stressed that “unlimited access to ART should be not given to everyone”.
an additional 60 days paid advanced leave, on
A role for the private sector?
top of the 90 days maternity leave. In addition,
the company has a policy for pregnant workers to
Responsibility for creating a family friendly
only work during office hours from 7.30am to 5pm,
environment does not rest solely on the state, and
Monday to Friday. The manufacturer also portrays
companies should be encouraged to support their
itself as a model company with breastfeeding
workforce. An example of what can be done can
friendly policies. Besides provision of breastfeeding
be found in Thailand, where a computer hardware
rooms, breastfeeding supplies and allowing breaks
manufacturer has a workforce of about 90%
for breast milk expressing, a pre-delivery training
women. The company has supportive maternity
program on breastfeeding is held in the factories
benefits and policies, in addition to those laid out
for expectant mothers.
in the labour law. For instance, workers can take
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Opportunities for improvement: what does
the evidence say?
S outheast Asia is becoming ever-more urbanised, with increased female participation in the labour
force. Support for women is therefore needed as they juggle the responsibilities of both work and
home. With export-oriented growth driving economic development, the Asian Development Bank
reports that the expansion of low-skill manufacturing jobs will bring about yet higher female labour
force participation in developing countries.29 It’s been suggested that closing the gender gap between
male and female labour force participation will generate a 30% increase in per capita income in a single
generation.29 Therefore policies are necessary to decrease both the actual- and opportunity-cost of
childbirth and child rearing, without disincentivizing work for women; to allow countries to enjoy both
high female labour force participation and sustainable fertility rates.29
However, assessing the effectiveness of policies to increase fertility rate is challenging. Policies need
to be in place for a long time before they have an impact, and any impact is likely to vary depending
on ethnicity, local culture or socioeconomic status; families may respond differently to the same
pro-natalist policy. While traditional policies of parental leave are still a necessity, it is likely that a
combination of well-rounded policies that address the specific needs of Southeast Asia will be needed
to raise fertility rates. This section aims to identify some areas of focus that need to be addressed to
support this demographic and societal shift.
Parental leave for both husbands and wives to encourage equal division of
work in the family
A study by Haghdoost and colleagues on policy-makers’ perceptions of how to increase fertility rates
in Iran emphasized the need to formulate policies around working women: policies should decrease
women’s workload, while ensuring maternity leave and job security.18 In Singapore, the Institute of
Policy Studies reported that 94.5% of surveyed women are aware of the maternity leave benefits in the
Marriage and Parenthood Package, and that these benefits have the greatest influence over women
across all ages when thinking about having a child.47 The duration of maternity leave is important for
mothers; sufficient time is required for recovery and to provide care to their children.30 But evidence
suggests that while maternity leave cannot be too short, it should also not be too long.30 Prolonging
maternity leave may be unpopular among employers and jeopardize women’s job security as
employers may be less likely to hire married women.18 In Russia, for example, fewer mothers of children
below three years of age are employed than in the past.48 Hence, Elizarov and Levin recommend
optimising the length of maternity leave to ensure job security.48
While the length of paid maternity leave has been extended over the years, providing paid paternity
leave would further encourage and underline the husbands’ role in the household. Except for Singapore
and Myanmar, most Southeast Asian countries do not provide paid paternity leave; or rather, the length
of entitled paid paternity leave is insufficient. For men in Singapore considering becoming a father,
the Institute of Policy Studies reports that the option of shared parental leave and paternity leave has
the highest influence on their decision making,47 a view echoed by Haghdoost and colleagues in Iran.18
Indeed, shared parental leave—whereby working fathers are allowed to take a portion of their wives’
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maternity leave—in addition to paternity leave, would provide couples with flexibility and encourage
parental responsibility from both partners.49 Granting infant and child care leave would also allow both
parents to care and spend quality time with their children in their first few years.
Workplace regulations to help balance work and family duties
Another policy area that is worth developing further is family friendly practices in the workplace.
Employment policies, such as flexibility in work hours to foster better work-life balance, would
encourage mothers to stay at work.50, 51 The fact that female employees are more interested in flexible
work than their male counterparts serves to highlight the gendered division of the workforce in South
East Asia, where it is the women’s responsibility to sacrifice her career and take care of the home.51
Professor Gray from Thailand recommends that work-life balance could encourage more births
because “when working mothers give birth, they need the flexibility to work and take care of their
children”. In addition, Dr Tey from Malaysia emphasized the “need to cater to women’s needs in the
workforce, because either they quit their jobs for childbearing, or they quit childbearing”. Women
working in stressful environments for longer hours have fewer children than average.20
But offering flexibility is not just about looking after the home. Flexible leave was the highest ranked
family friendly policy among Malaysians working in the central business region in Kuala Lumpur:
respondents said it would allow more time for them to socialise and improve their social networks.
Generally, flexible work arrangements improve both quality of life and contentment at a workplace, for
both men and women.52
However, family friendly employment policies are dependent on a supportive organisational
culture.50 Information on allowances and policies have to be made known to employees, and employers
need to be supported.50 Policies should therefore be legislated into employment law to ensure they are
practised consistently across both public and private sectors. This is not presently the case: a common
remark made by most respondents is that civil servants receive better welfare in central government
sectors (compared to private sector employees or non-central government civil servants). Professor
Prachuabmoh from Thailand commented that ‘the government must be able to incentivise employers
in the private sector to give more leave for women at work”, to ensure that employees in the private
sector receive the same benefits as those working for the government.
Breastfeeding support policies and child care centres at the workplace
Breastfeeding policies at the workplace provide a supportive work environment for new mothers.
Breastfeeding is beneficial for the health of both mother and child, and the WHO recommends
exclusive breastfeeding for six months after birth.53 However, most working women discontinue
breastfeeding when they return to the workforce. Provision of breastfeeding rooms, breastfeeding
supplies and allowing break time for breast milk pumping are some initiatives to support new
mothers and promote breastfeeding.51 Dr Wasanthanarat from Thailand believes that such initiatives
are particularly important for women working in factories, compared to those holding office jobs.
According to ASEAN, a large proportion of women work in the production sector, engaging in labour
intensive production;13 in Thailand, 48% of employed women work in factories.54
Provision of workplace child care centres would also help working mothers juggle their
responsibilities. Dr Tey observed that it is a challenge for working mothers to find caregivers, while
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sending their children to child care centres may be prohibitively expensive. With more women
migrating from rural to suburban and urban areas for work, Professor Gray recommends “employers to
build child care centres at their workplaces, especially in the private sector; [for which] the government
must provide [financial] support”. This is starting to happen, at least in the government sector: in
Malaysia, a grant of RM200,000 is given to support government agencies in renovation and furnishing
child care centres at their facilities.33 Such centres would not only foster maternal and child bonding,
but boost breastfeeding rates as well.53 Indeed, a recent study in Malaysia showed that child care
centre services at the workplace increased employees’ morale, improved productivity and reduced
absenteeism.50
Tax relief, cash incentives and child care subsidies
While parents, no doubt, welcome financial support through tax relief and cash incentives for
childbirth, the evidence is unclear on whether they encourage individuals to have larger family sizes.55
Gauthier and colleagues reviewed the evidence on child allowances and found that while they have
an effect on the timing of births—encouraging earlier rather than later births—they did not influence
the number of children.56 Conversely, cash benefits were associated with increased fertility in Quebec,
Canada, when a cash allowance of $8,000 was initiated. An increase in fertility rate was observed with
the introduction of the scheme in 1988, and a decreased with its cancellation in 1997.57 Others have
highlighted that temporary financial incentive policies are unlikely to offset the impacts of broader
social and economic changes on fertility decisions.58
Another way government can try to support families is the provision of subsidised child care. Hann
and Wrohlich suggest that working mothers benefit from the provision of subsidised care as it helps
them to balance their work and family responsibilities.59 It was also found that subsidised child care
helps to increase employment and working hours, particularly in the case of highly educated women.59
Another review concluded that the provision of affordable child care reduced the longer-term financial
burden on childbearing, and was therefore likely to increase fertility more than providing child
subsidies.60
While the provision of affordable child care can help parents combine work and family
responsibilities, low uptake can limit its effectiveness. For example, Gauthier and colleagues observed
low enrolment of young children in child care in Eastern Europe, and associated it with the need to
take prolonged parental leave, which in turn reduced the demand for childcare.55 Closer to home, while
the Malaysian government enthusiastically encouraged the establishment of child care centres at the
workplace for civil servants, there is a lack of child care support in the private sector.50
Improving access to and affordability of ART
Increases in ART births tend to be associated with the introduction of subsidised ART. For example,
when the Singaporean government provided subsidies for ART in 2008 as part of the Marriage and
Parenthood package, ART births increased from 1.3% of the total number of births in 2006 to 3% in
2009.61 The provision of subsidized ART is particularly impactful for women in the their thirties rather
than twenties, as reported by the Institute of Policy Studies.61 Inhorn described how Egypt provides
state subsidies and accessibility to ART, despite being a low-income country with a large population,
and commended the government for its political will and pronatalist stance that helped ensure
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reproductive rights for otherwise infertile citizens.62 However, subsidising ART may lead to some
women being caught in a ‘perseverance trap’, which in turn could lead to psychological and physical
stress such as suffering side-effects from hormonal injections, finding their career interrupted or
experiencing relationship breakdowns.56
In Southeast Asia, the effect of ART to raise fertility is limited by geographical and economic factors.
While the number of ART facilities has increased in Vietnam to meet rising demand, ART services
remain unavailable in rural areas. Consequently, additional costs such as travel, accommodation and
the lengthy stay for treatment limits accessibility for the majority of Vietnamese people who live in
rural areas.46 Similarly, Purvis highlighted that infertility treatment is limited to metropolitan areas in
Indonesia, with specialists more likely to work in urban areas because of the opportunity for financial
gains in the private sector.63
Combined policies
The Institute of Policy Studies reports that maternity leave, parenthood tax and extended childcare
leave are the top three most influential measures in the Marriage and Parenthood Package for both
genders in Singapore.47 However, it is noteworthy that the considerations of child bearing is different
for men and women. Men tend to be more concerned about financial and work-lifestyle issues, while
women are concerned about career interruption.47
Consequently, there is arguably a need for combined policies to help address the concerns of both
genders: it takes two to have a baby. While the decision to start a family inevitably lies with individual
couples, packages of policies can encourage those who are hesitating to take the plunge by fostering a
supportive environment for childbirth and child raising.55
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